NURSING CARE PREPARATION

Student Name:

Jason Villavicencio

Unit/Room Number: IMCU/258

Age: 92
Gender: Male
Eriksons Developmental Level: Ego Integrity vs.
Despair

Date of Care:

02/18/14

Date of Admission: 02/16/14

Ethnic/Cultural Preferences:
White/Widowed/Firefighter-retired
Allergies: KNFA/KNDA
Code Status: DNR

Primary Diagnosis:
Gi bleed, acute anemia, afib, renal colic
Co-morbidities:
CHF/HTN, Arthritis, diverticulitis, kidney stone

Discharge Plan (add day of clinical):

Skilled nursing facility

Preliminary Integrated Pathophysiology primary diagnosis (what is going on with your client at the cellular
level for the health condition, due before clinical shift; (typed 1-3 pages with APA formatting). Explain how
your clients primary diagnosis, co-morbidities, medications and labs interrelate.

Data Collection (Record exactly what is written on the personal information sheet [aka Kardex]. Any
assessment/elaboration should be made on the assessment sheet):
Diet (Type): NPO/ex. Ice chips and sips-H2O
IV (Fluid type, rate, access type): Saline
lock/Antecubital/Rt
I&O (MD order/Nursing Order/Frequency):
CBG (Yes/No, frequency): no
Fall Risk/Safety Precautions (Yes/No):
Yes/High/Gown, wrist band, bed alarm

Activity (Patients activity level ): 1perAssist/adlib/fair

Wound Care (Yes/No): no

Oxygen (Yes/No, Delivery method, how much): NC/14Lpm >/= 93%

Last BM: unknown

Drains (Yes/No, Type): no

Other Tubes: no

ASSESSMENTS
(Include Subjective & Objective Data)
Integumentary:
BUE edema +2, dry, color purple, cool to touch, nails
intact, ridges, cap refill less than 1 sec. LE color and
hair normal for age; abdomen dry, color/hair
appropriate for age and race, color darker in exposed
areas; Distal UE bilaterally cool to touch, no tenting,
no clubbing, nails longitudinal ridges; Dorsal thorax
discrete nevi throughout, no irregular boarders, pain,
or exudate; Coccyx redness, BLE/BUE scratches

Eyes/Ear/Nose/Throat:
Wears classes reading, color vision intact
Diminished visual field, eyes parallel, light reflex
symmetrical, Extraocular motion intact OU, no
wandering, + corneal reflex, PERRLA, pupil 3-5mm
Ears: inability to repeat whispered words bilaterally,
external ear non-tender, no lesions
Nose symmetrical dry (NC), pink septum intact hair
appropriate for age.
Throat: Hard and soft palate pink and intact; tonsils
pink, symmetrical, +1, no exudate; uvula symmetrical,
+ swallow and gag, no masses.

Head and Neck:

Head: Normocephalic, erect, midline, alopecia
Facial expression flat
Hair distribution appropriate for age, sex, and
ethnicity.
No lesions or abnormal movement
No periorbital edema
Sinuses no pain or swelling
Lips moist pink no visible lesions
Dentures top and bottom gingiva pink moist
Neck midline AROM + swallow and gag reflex, skin
intact
Larynx and trachea rise with swallowing
Thyroid no swelling non-tender, rough
Thorax/Lungs:
Respirations quiet, symmetrical, regular rhythm and
depth while sedentary, becomes labored with activity
and conversation, clear, no crepitus; No barrel chest
or spinal deformities
Chest non-tender, no masses
E to A consolidation BLL
Diminished sounds LLL
No fremitus, Crackles/rales, wheezing

Cardiac:
Visible cardiac pulsation; JVP >3cm; Precordium
+pulse at apex; Neck vessels pulse equal, +2, no
thrills, irregular rhythm, no bruit, variable S1, atrial
flutter, SCDs ordered

Musculoskeletal:
Rheumatoid Arthritis BUE
UE bilaterally ROM weak strength +1
Neck AROM limited
Assist with repositioning 2person
LE bilaterally ROM limited strength +1
Bed rest

Genitourinary:
Foley Catheter, yellow, some odor 360ml 5h
Penis: intact light brown, no lesions or discharge,
uncircumcised, soft, nontender, no nodules.
Scrotum: rough without lesions, hair appropriate for
age and race

Gastrointestinal:
Pain in LUQ sharp, acute with movement, 8 on 1-10
pain scale with movement.
auscultated in all 4 quadrants, gastric sounds <15 sec
Hypoactive sounds all quadrants except LLQ;
hair/color consistent with race, age, gender; No
lesions, protuberant, Soft, nontender, no bulges
Other (Include vital signs, weight):
T: 98.4 P: 110 R: 18 BP: 148/68 SpO2:98% NC 1Lpm

Neurological / Psychosocial
AAOX3 clear speech, cooperative, agitated at times,

disoriented to time.
Pain (chronic or acute): Acute 5/10 on 0/10 scale
Pain management: Reposition/Norco

CURRENT MEDICATIONS
List ALL regularly scheduled and prn medications scheduled on your client.
(Due morning of clinical)
Generic &
Trade Name

Classification

Dose/Route/
Rate if IV

Lidocaine
patch
(lidoderm)

Class 1B
antiarrhythmic;
local anesthetic
(amide type)

5%
1 daily 12h
on 12h off

Saline Flush
(Sodium
Chloride Flush)

Mineral
Electrolyte
Replacement

1 each IV Q
Shift

Amiodarone
(Pacerone)

Isotonic
Antiarrhythmic;
Antianginal

Fentanyl Patch
(Duragesic)

Analgesic;
Narcotic

50mg= 0.5
tab PO Daily

25mcg/h=
1TD q72h for
7d

Onset/
Peak

Intended
Action/Therapeutic
use. Why is this
client taking med?
Onset
Suppress
45automaticity in HIS90sec
Purkinje system of
Half life
the heart and
1.5-2h
elevates electrical
stimulation threshold
of ventricle during
diastole . Prompt,
intense, and longer
lasting local
anesthetic than
procaine.
O:
Used to flush IV
Unkno
wn

Adverse reactions
(1 major side
effect)

Nursing Implications for this client. (No

more than one)

Respiratory
depression

Auscultate lungs for basilar rales,

especially in patients who tend to
metabolize the drug slowly (e.g., CHF,
cardiogenic shock, hepatic dysfunction).

Edema

Assess fluid balance (intake and output,

daily weight, edema, lung sounds).

O: PO
2-3d/13wk
P: 3-7h

Fatigue, dizziness,
weakness

Monitor s/s drowsiness, dizziness,

orthostatic hypotension, and fall
precautions.

Irritation,
impaired skin
integrity

Monitor VS and skin integrity for s/s of

impairment.

Treatment
ventricular
arrhythmias and
supraventricular
arrhythmias
particularly with
atrial fibrillation
Acute pain

Nystatin oral
susp
(Mycostatin
Oral Susp)
Pantoprazole
(Protonix)

Solifenacin
(vesicare)

Sucralfate

Antifungal

500,000 unit
= 5mL PO QID

None
listed

Fungistatic and
fungicidal activity
against a variety of
yeasts and fungi.

Nausea &
vomiting

Monitor oral cavity, especially the tongue,

for signs of improvement.

Gastric proton
pump inhibitor;
Antisecretory

40mg = 10mL
IV push q12h

Peak
2.4h
Half life
1h

Abdominal pain

Monitor for and immediately report S&S

of angioedema (welts or swelling of the
skin) or a severe skin reaction.

Anticholinergic;
Antimuscarinic;
antispasmodic

5mg 1tab PO
daily

Peak 38h
Half
life 4568h

Suppresses gastric
acid secretion by
inhibiting the acid
(proton H+) pump in
the parietal cells
Improves the volume
of urine per void and
reduces the
frequency of
incontinent and
urgency episodes

Upper abdominal
pain

Monitor bladder function and report

promptly urinary retention (This will be
done with I&O monitoring)

Antiulcer;
gastroadhesive

1GM = 10mL
po achs

Onset
0.5-1
min

Respiratory
depression

Be aware that transient apnea usually

occurs at time of maximal drug effect (12min); spontaneous respiration should
return in a few seconds or at most, 3 or 4.

Vitamin D
Analog

2000 iu
Po daily

Anaphylaxis

Narcotic

7.5/325mg
PO
Q6h PRN
Pain

Onset
2-6h
Peak
10-12h
1020min
onset
1.5-3hr

Have readily available parenteral calcium,

particularly during early therapy.
Hypocalcemic tetany is a theoretical
possibility.
Monitor for effectiveness of drug for pain
relief.

(carafte)

Vit D
(calcitriol)
Norco
(hydrocodone
bitartrate)

Absorbs bile, inhibits

the enzyme pepsin
and blocks diffusion
of H+ ions. These
actions plus
adherence of the
paste-like complex
protect damaged
mucosa against
further destruction
from ulcerogenic
secretions and drugs.
Synthetic form of
active metabolite of
ergocalciferol
(vitamin D2).
CNS depressant with
moderate to severe
relief of pain

Respiratory
depression,
constipation

(Labored breathing, dyspnea, cyanosis,

Ondansetron
(zofran)

Artificial Tears
(ISOPT0 TEARs
OPH)

moderate

peak

5-HT
Antagonist;
Antiemetic

4mg= 2mL IV
q4h prn N/V

Peak 11.5h
Halflife 3h

Ocular lubricant

2 GTT
O.U.
PRN

Unkno
wn

low Spo2)
Prevents nausea and
vomiting associated
with cancer
chemotherapy and
anesthesia
Dry eyes

headache

Monitor fluid and electrolyte status.

Diarrhea, which may cause fluid and
electrolyte imbalance, is a potential
adverse effect of the drug. (Monitor I&O)

Blurred vision

Monitor for subjective data including

burning, stinging, and pain

DIAGNOSTIC TESTING
Include pertinent labs [ABGs, INRs, cultures, etc] & other diagnostic reports [X-rays, CT, MRI, U/S, etc.]
NOTE: Adult values indicated. If client is newborn or elder, normal value range may be different.
Date
Lab Test
Patient Values/
Interpretation as related to Pathophysiology
Normal Values
Date of care
cite reference & pg #
Sodium
135 145 mEq/L
Potassium
3.5 5.0 mEq/L
Chloride
97-107 mEq/L
Co2
23-29 mEq/L
Glucose
75 110 mg/dL
BUN
8-21 mg/dL
Creatinine
0.5 1.2 mg/dL
Uric Acid Plasma
4.4-7.6 mg/dL
Calcium
8.2-10.2 mg/dL

Phosphorus
2.5-4.5 mg/dL
Total Bilirubin
0.3-1.2 mg/dL
Total Protein
6.0-8.0 gm/dL
Albumin
3.4-4.8gm/dL
Cholesterol
<200-240 mg/dL
Alk Phos
25-142 IU/L
SGOT or AST
10 48 IU/L
LDH
70-185 IU/L
CPK
38-174 IU/L
WBC
4.5 11.0
RBC
male: 4.7-5.14 x 10
female: 4.2-4.87 x 10

HGB
male: 12.6-17.4 g/dL
female: 11.7-16.1 g/dL

HCT
male: 43-49%
female: 38-44%

114H

1.22H

Indicator of damaged nephrons possibly from

infection in kidneys. (Laboratory Tests and
Diagnostic Procedures 8th Ed. Pg 89)

8.1L

Pt experienced severe anemia, required X2 units

blood, causing severe malnutrition resulting in
lower calcium levels. . (Laboratory Tests and
Diagnostic Procedures 8th Ed. Pg 163)

3.12L

Indicator of abnormal loss or destruction of

erythrocytes ((Laboratory Tests and Diagnostic
Procedures 8th Ed. Pg 28)
Levels directly correlate with RBC (Laboratory
Tests and Diagnostic Procedures 8th Ed. Pg 27)
Low levels indicate true decrease in RBCs
(Laboratory Tests and Diagnostic Procedures 8th
Ed. Pg 27)

9.1L
28L

MCV
85-95 fL
MCH
28 32 Pg
RDW
11.6-14.8%

17.4H

High levels combined with norm MCV, MCH

indicates an acute blood loss. (Laboratory Tests
and Diagnostic Procedures 8th Ed. Pg.36)

Platelet
150-450

DIAGNOSTIC TESTING
Date

UA

Normal
Range

Results

Interpretation as related to
Pathophysiology cite reference &
pg #

Color/Appearance
pH
Spec Gravity
Protein
Glucose
Ketones
Blood
Date

Other
(PT, aPTT, PTT, INR,
ABGs, Cultures,
etc)

Normal
Range

Results

Date
Radiology
X-Rays: 1 Chest
View
Scans: CT
Head/Brain
02/16/14 EKG-12 lead
Telemetry
Other

Results

1st degree heart block

Interpretation as related to
Pathophysiology cite reference &
pg #

Interpretation as related to
Pathophysiology cite reference &
pg #

DAR NURSING PROGRESS NOTE

Include the same note that was written in the client record for the priority nursing diagnostic
statement.
Include the date/time/signature.
1600 02/18/14 Pt needed to take scheduled PO meds, no orders by physician for stop NPO. Notified Dr. for
change in order. Ordered transitional diet. Med admin. per MAK. Meal ordered for dinner. Pt tolerated 25%
of meal. --------------------------------------------------------------------------------------------------------J. Villavicencio, SN

PATIENT CARE PLAN

Patient Information: 92 year old male, room 258, IMCU, c/o gi bleed.

Nursing Diagnosis should include Nanda Nursing Diagnostic statement, related to (R/T), as evidenced by (AEB).

Problem #1: Imbalanced nutrition, less than body requirements r/t gi bleed aeb <25% meal consumption
Desired Outcome: Pt will increase meal intake to levels greater than 25% by 2000 02/18/14
Nursing Interventions
Client Response to Intervention
1. Assist with meal as needed.
1. Pt tolerated 25% of meal with total assist.
2. Assess pt willingness and ability to eat.

2. Pt was willing and encouraged to eat. Pt was

not able to feed self.
3. Pt ate 25% of meal, fluid intake was 400ml

3. Monitor recorded intake for nutritional content and

calories.
Evaluation (evaluate goal & interventions, what worked/what didnt, what would you adapt if needed):
Pt started out shift with NPO order; order was changed to transitional diet. Pt tolerated 25% of meal. Pt
verbalized readiness for improved diet. Goal was not met. Goal needed to be increase meal intake from NPO
as tolerated.
Problem #2: Risk for impaired skin integrity r/t urine and bowel incontinence
Desired Outcome: Pt will remain or sustain current skin integrity throughout 1500-2200 shift
Nursing Interventions
Client Response to Intervention
1. Assess pt skin integrity at beginning of shift for rash,
1. Skin flaky, dry, cool in extremities.
temp, color, moisture.
2. Reposition pt q2h or as requested
2. Pt was able to reposition as needed and did
so with reminder q2h.
3. Preform hourly incontinence checks and cleans at time
3. Pt was not incontinent, foley catheter
of soiling.
ordered early am 2/18/14. Pt was checked
hourly.
Evaluation:
Goal was achieved as pts skin integrity remain consistent throughout shift.

Problem #1 Decreased cardiac output r/t abnormal heart rate or rhythm AEB tachycardia
Desired Outcome: Pt will remain free from complications r/t arrhythmia throughout AM shift.
Nursing Interventions
Client Response to Intervention
1. Monitor VS for irregularities
1. Pt VS were consistent throughout shift
2. Administer medications (Paverone) as indicated by
2. Rx was admin in am
MAK
3.Educate pt about s/s to report immediately
3. Pt was able to repeat teaching with

coaching. Further teaching required.

Evaluation: Pt has Atrial flutter, HR tachy, irregular with gallop. Goal was not achieved, unrealistic.

Running head: PATHOPHYSIOLOGY AT A CELLULAR LEVEL

Pathophysiology at a Cellular Level

Lower Gastrointestinal Bleed
Jason Villavicencio, SN
Southwestern Oregon Community College
02/18/14

Running head: PATHOPHYSIOLOGY AT A CELLULAR LEVEL

My Patient
The patient, a 92 year old male retired firefighter, was admitted on February 16th with
suspected lower gastrointestinal bleeding. He presented with frank stool, acute anemia, renal
colic, dysthymia, and disorientation. The patient has a history of congestive heart failure,
hypertension, kidney stones, and diverticulitis.
Diagnosis at a Cellular Level
Gastrointestinal (GI) bleeding is bleeding anywhere in the intestinal tract. The bleed can
present itself in various ways such as, dark, tarry stools, frank stools (bright red in color), blood
in toilet, and vomiting blood (Dugdale, 2011). These are obvious indicators. GI bleeds can also
be less obvious only presenting in lab tests of feces. Depending on the severity of the bleed, GI
bleeds can be dangerous or life-threatening (Dugdale, 2011). GI bleeds are usually classified
into two categories, lower and upper.
Co-morbidities, Medications and Lab (and how they reflect/interact on the disease)
The patient has a history of diverticulosis which can result in GI bleeding if exacerbated.
Old age may also play a key role in the patients diagnoses. Hypertension causes resistance to
blood flow systemically, which can cause ineffective perfusion in the bowls for metabolic
digestion of nutrients and motility. Both can cause constipation leading to probable
inflammation or infection. The patient also has severe arthritis which could inhibit fluid and
nutrition intake adding to GI immotility.
Conclusion
Patient has order for comfort care and is now on a transitional diet from not per
mouth order. This is a good indicator of improvement. Patient also welcomed therapy stating,

Running head: PATHOPHYSIOLOGY AT A CELLULAR LEVEL

Whatever it takes for me to get better. Patient is taking an antiarrhythmic for an atrial flutter
and antisecretory for peptic ulcers. He is also taking Norco for pain. Physician indicated with
improvement patient could be discharged within the next 48 hours. Patients extremity
movements have increased throughout shift.

Running head: PATHOPHYSIOLOGY AT A CELLULAR LEVEL

References
Dugdale, I. D. (2011, January 31). Gastrointestinal Bleeding. Retrieved from
MedlinePlus: http://www.nlm.nih.gov/medlineplus/ency/article/003133.htm
Huether, S. E., & McCance, K. L. (2012). Understanding Pathophysiology. St. Louis,
MO: Mosby Elsevier.